Introduction to Orthotics Tammy J. LeSage MOT OTR/L, CHT Elisabeth McGee DPT, MOT, PT, OTR/L, CHT, MTC

Guess Who???

Splint or Orthosis What are your thoughts about the terms? http://www.asht.org/practice/l-codes

Why Orthotics for OT? Uses of Orthoses for OT How can you use ?

Client-Centered Bio-occupational Approach Rehabilitation of the Hand and Upper Extremity, 2011

History of Orthotics Physical rehab – WWII (1939 – 1945) Sterling Burnell MD Splints/orthotic devices commercially available – 1940’s Splints/ orthotic devices for function – 1950’s polio Low temperature thermoplastics (temps 135 – 180 degrees) 1960’s

Anatomical Structures of Importance for Orthotics Wrist Digits Thumb Muscles and Tendons Nerve Supply Blood Supply Arches of the Hand Creases of the Hand Prehension and Grasp Patterns

Wrist – Joints and Ligaments Radiocarpal Joint Midcarpal Joint Distal Radioulnar Joint Ligaments Intrinsic Ligaments Extrinsic Ligaments

The Hand Examination and Diagnosis, 3rd Ed., 1990

The Hand Examination and Diagnosis, 3rd Ed., 1990

Digits – MCP, PIP, DIP Joints Metacarpals – two joints each Carpal bone articulation Metacarpophalangeal joints – MCP/ MP joints. Ligaments Collateral Ligaments Volar Plate

MCP’s extension = shortening of laxed collateral ligaments – contraction and adherence of volar plate ***Contracture of the MCP’s in extension results in decreased flexion of the MCP’s and decreased function of the hand.

Proximal Phalanx & Distal Phalanx Both are hinge joints – flexion/ extension Ligaments Collateral Ligaments Volar plate

The Hand Examination and Diagnosis, 3rd Ed., 1990

The PIP joint is very susceptible to adhesion and flexion contracture. Position of the PIP/ DIP joints to prevent contracture is opposite of MCP joint. The PIP joint is very susceptible to adhesion and flexion contracture.

Safe Position Orthotic Device MCP flexion with IP (PIP/DIP) extension Why???? The Hand Examination and Diagnosis, 3rd Ed., 1990

To prevent deformity!! Especially if edema is present. ** there are some injuries/ diagnoses that state differently and are exceptions to this

Thumb – Joints and Ligaments Carpometacarpal (CMC) Joint Metacarpophalangeal (MP) Joint Interphalangeal (IP) Joint Ligaments Collateral ligaments

Muscles and Tendons of the Hand Extrinsic Muscles of the Hand Intrinsic Muscles of the Hand

Extrinsic Muscles of the Hand Two groups: Extensor muscle group Flexor muscle group Each has a retinacular system Extensor retinacular system Flexor retinacular system Digital pulley system

Extrinsic Extensor Tendons APL, EPB ECRL, ECRB EPL EDC, EIP EDM ECU

Extrinsic Flexor Tendons FDS index – small FDP index – small FPL

How can this affect design of orthotic device?? What is Tenodesis? How can this affect design of orthotic device??

Decreased wrist motion, due to joint or extrinsic tendons? How can you evaluate? How would you position in orthotic device to increase motion???

Intrinsic Muscles of the Hand Organize them in three compartments Thenar eminence OP, FPB, APB, AP Hypothenar eminence ADM, FDM, ODM, PB Central Compartment Lumbricals x 4 Interossei – 4 dorsal, 3 palmar

What is an intrinsic plus position? Intrinsic minus hand? How would you position in orthotic device?

Intrinsic Vs Extrinsic Tightness Digits Extrinsic Flexor Tightness What is it? How would you position it? Extrinsic Extensor Tightness Intrinsic Tightness What is it? How would you position?

Nerve Supply Considerations with Orthotic Devices Areas of pressure by orthosis upon nerves Decrease sensation due to peripheral nerve disruption. Decrease peripheral nerve motor function leading to muscle imbalance and dysfunctional posturing of the hand.

Common areas of pressure When fabricating an orthosis, you want to avoid applying pressure over sites where the nerve is superficial and prone to compression. Ulnar nerve – a) elbow b) guyon’s canal Radial nerve – a) elbow b) dorsal/ radial anatomical snuffbox Digital nerves – lateral borders of fingers and thumb

Decrease Sensation Peripheral Nerve Disruption Sensory Nerve Distribution Radial, Ulnar, Median Nerves Care must be taken with orthotic device Monitor skin, check for area of abrasion or irritation.

The Hand Examination and Diagnosis, 3rd Ed., 1990

Decreased Peripheral Nerve Motor Function Leads to muscle imbalance and dysfunctional posturing of the hand. Radial Nerve – wrist drop, decreases MP extension digits, thumb extension. How would you position? Ulnar Nerve – Flat hand, claw hand ring and small fingers How would you how would you position? Median nerve – Decreased thumb function

The Hand Examination and Diagnosis, 3rd Ed., 1990

Radial Nerve Orthosis Used with permission from Sammons Preston

The Hand Examination and Diagnosis, 3rd Ed., 1990

Ulnar Nerve Orthosis Used with permission from Sammons Preston

The Hand Examination and Diagnosis, 3rd Ed., 1990

Median Nerve Orthosis Used with permission from Sammons Preston

Blood Supply to the Hand Ulnar Artery, Radial Artery Superficial Palmar Arch, Deep Palmar Arch Common digital arteries, digital arteries Care must be taken when splinting not to compress on arteries to compromise circulation

The Hand Examination and Diagnosis, 3rd Ed., 1990

Arches of the Hand The intrinsic musculature has an important relationship with the arches. Collapse of the arches can contribute to severe disability and deformity Proximal Transverse Arch Distal row of carpal bones Fixed arch without much motion Distal Transverse Arch Distal palmar crease Mobile arch Longitudinal Arch Longitudinal axis of each finger Rigid and mobile portions

The Hand Examination and Diagnosis, 3rd Ed., 1990

Creases of the Hand Distal Digital Crease Middle Digital Crease Proximal Digital Crease Distal Palmar Crease Proximal Plamar Crease Thenar Crease Distal Wrist Crease Proximal Wrist Crease

The Hand Examination and Diagnosis, 3rd Ed., 1990

Functional Prehension, Grasp Patterns, and Manipulation Skills

Functional Prehension Patterns Prehensile movements: incorporate grasping of an object and can be subdivided into having two purposes, precision grasp and power grasp. Precision grasp: uses opposition of the thumb to the fingertips Power grasp: uses the whole hand with thumb flexion or abduction according to the control needed for the task

Functional Grip Patterns A position of the hand that facilitates contact of an object against the palm and palmar surface of the partially flexed digits. Cylindrical grip Spherical grip Hook grip Intrinsic plus grasp Disc grasp

Manipulation Skills Finger-to-palm translation Palm-to-finger translation Shift Demonstrated when an object that is being held on the radial aspect of the hand is moved linearly on the finger surface in order to reposition it on the finger pads (e.g. repositioning a pen after grasping it) Rotation E.g. Rotating a pen to use the eraser In-hand manipulation with stabilization E.g. Picking up coins while holding them in their palm